Educational Attainment and HIV Prevalence by Age Among Pregnant Women in South Africa

We examined the association between educational attainment and HIV positivity among pregnant women in a high HIV-prevalence setting and assessed how this relationship varies by age to inform targeted prevention strategies. This cross-sectional study included 2003 pregnant women aged 21-44 years attending their first antenatal visit (<27 weeks' gestation) at four public health facilities in East London, South Africa, between March 2021 and May 2024. Educational attainment was categorized as pre-high school (< grade 10), high school (grades 10-12), diploma (post-high school), or degree (associate's or bachelor's). Age was categorized into four groups (21-24, 25-29, 30-34, and 35-44 years). HIV status was determined through routine antenatal testing. We used logistic regression to assess associations between educational attainment and HIV positivity, adjusting for age, partner's HIV status, and participant sexually transmitted infection (STI) status. Overall HIV prevalence was 31.0% (95% CI, 28.9%-33.0%). Compared with women with less than a high school education, the odds of HIV infection were lower among women who attained high school education (adjusted odds ratio [AOR], 0.59; 95% CI, 0.40-0.87), a diploma (AOR, 0.40; 95% CI, 0.24-0.67), or a degree (AOR, 0.21; 95% CI, 0.09-0.43). However, this inverse association was not observed among women aged 35-44 years. In conclusion, higher educational attainment was associated with lower HIV prevalence among pregnant women, but this protective association diminished with increasing age. HIV prevention strategies should account for both socioeconomic factors and age-related interpersonal dynamics influencing HIV vulnerability.